A geographic relation between alcohol availability and gonorrhea rates

Alcohol availability and prevalent Chlamydia trachomatis in young Australians: a multi-level analysis

Background Prevalence of sexually transmissible infections (STIs) has been associated with availability of alcohol. This paper investigates potential associations between prevalent cases of chlamydia in young people in Australia and the availability of alcohol within their local area, defined as postcode of residence. Methods Alcohol availability was determined at the postcode level using liquor licensing data, classified as total number of licences, number of 'take-away' licences and number of licenses by population. Participant data were drawn from a survey targeting Australians aged 16-29years in rural and regional Australia, capturing demographic details including postcode of residence, indicators of sexual behaviour including condom use and chlamydia test results. Mixed-effects logistic regression was used to examine potential associations between first, alcohol availability and chlamydia, and second, between condom use and chlamydia. Results We found little evidence of associations between alcohol availability and chlamydia in either unadjusted or adjusted models. After adjusting for alcohol availability, we observed significant associations between inconsistent condom use and chlamydia prevalence, whether alcohol availability was measured as total number (adjusted odds ratio (AOR) 2.20; 95% confidence interval (CI) 1.20, 3.70), number of take-away licenses (AOR 2.19; 95% CI1.30, 3.69) or licenses per 1000 population (AOR 2.19; 95% CI 1.30, 3.68). Conclusion Little evidence of association between alcohol availability and chlamydia at the postcode level was found. Further research is required to determine appropriate measures of 'local area' and how characteristics thereof may impact on sexual health.

Looking Back and Moving Forward: The Evolution and Potential Opportunities for the Future of Alcohol Outlet Density Measurement

The literature consistently finds that areas with greater density of alcohol outlets (places that sell alcohol) tend to have higher levels of public health harms. However, conflicting findings arise when researchers drill down to identify the type(s) of alcohol outlets with the strongest associations with harms and the mechanisms that explain these associations. These disagreements could be a result of the outdated methods commonly used to quantify the alcohol environment: counts of the number of outlets in an area. This manuscript reviews the events and ideas that shaped the literature on the physical alcohol environment. It then defines the three main methods used to measure alcohol outlet density, conducts an exploratory factor analysis to explore the constructs underlying each method, and presents a novel conceptual framework that summarizes the three methods, their respective underlying constructs, and the setting(s) in which each may be most appropriate. The framework proposes that counts of alcohol outlets measure availability, proximity to the nearest outlet measures accessibility, and spatial access measures measure access, which comprises both availability and accessibility. We argue that researchers should consider using proximity and spatial access measures when possible and outline how doing so may present opportunities to advance theory and the design and implementation of alcohol outlet zoning regulations. Finally, this manuscript draws on research from other areas of the built environment to suggest opportunities to use novel methods to overcome common hurdles (e.g., separating subtypes of outlets, ecologic designs) and a new challenge on the horizon: home delivery.

Protective Factors as an Explanation for the "Paradox" of Black-White Differences in Heavy Drinking

BACKGROUND

African Americans are generally known to have lower heavy drinking prevalence than Whites despite often greater individual and community risk factors. While it is supposed that their protective resources explain this "paradox," studies have not explicitly examined this.

OBJECTIVE

Assess the contribution of protective resources to Black-White differences in heavy drinking, and (secondarily) whether protective resources operate by reducing heavy drinking and/or increasing abstinence.

METHODS

Using data from the 2009-2010 U.S. National Alcohol Survey (N = 3,133 Whites and 1,040 Blacks ages 18+), we applied propensity score (PS) weighting to estimate racial differences in heavy drinking and abstinence under hypothetical conditions in which Whites are similar to Blacks in: (1) age and marital status; (2) socioeconomic position and unfair treatment; (3) neighborhood socioeconomic conditions and alcohol outlet density; and (4) protective resources (proscriptive religiosity, area-level religiosity, "drier" network drinking norms and patterns, and family social support).

RESULTS

The Black-White gap in male and female drinkers' baseline heavy drinking increased after weighting adjustments for demographics. In women, this gap was reduced after weighting on disadvantage and eliminated after adjusting for protective resources. In men, adjustment for disadvantage increased the racial gap, and protective resources reduced it. Protective resources had a stronger effect on Black-White differences in men's abstinence than heavy drinking, but similar effects on these outcomes in women.

CONCLUSION

Protective resources help explain Black-White differences in men's and particularly women's heavy drinking. Future research is needed to elucidate mechanisms of action and additional factors underlying racial differences in men's heavy drinking.

Alcohol retail sales licenses and sexually transmitted infections in Texas counties, 2008-2015

BACKGROUND

Research suggests that reduced retail alcohol outlet density may be associated with lower prevalence of HIV and other sexually transmitted infections (STIs). On-premise sale of alcohol for immediate consumption is theorized as increasing social interactions that can lead to sexual encounters.

OBJECTIVE

We examined associations between on- and off-premise retail alcohol sales licenses and number of newly diagnosed HIV and STI cases in Texas counties.

METHODS

Retail alcohol sales license data were obtained from the Texas Alcoholic Beverage Commission. HIV and bacterial STI data were obtained from the Texas Department of State Health Services. Associations between retail alcohol sales licenses and STIs were estimated using spatial linear models and Poisson mixed effects models for over-dispersed count data.

RESULTS

Adjusting for county-specific confounders, there was no evidence of residual spatial correlation. In Poisson models, each additional on-premise (e.g., bar and restaurant) alcohol license per 10,000 population in a county was associated with a 1.5% increase (95% CI: 0.4%, 2.6%) in the rate of HIV and a 2.4% increase (95% CI: 1.9%, 3.0%) in the rate of bacterial STIs, adjusting for potential confounders. In contrast, number of off-premise licenses (e.g., take-out stores) was inversely associated with the incidence of STI and HIV, although the association with HIV was not statistically significant.

CONCLUSIONS

This study adds to the limited literature on the association between retail alcohol availability and STIs. Additional research is needed on the role of alcohol availability (and policies affecting availability) in the spread of HIV and other STIs.

Defining and Assessing Organizational Competence in Serving Communities at Risk for Sexually Transmitted Diseases

This study sought to develop an assessment tool to help health agencies enhance their capacity to provide sexually transmitted disease (STD) care to communities at risk and close the gap of racial disparities in health. Specifically, the study sought to (a) define the organizational competence of agencies serving communities at risk for STDs, and (b) develop a method to assess an agency’s organizational competence. In a rural Southern county, qualitative action research methods including key informant interviews, observation, and document review were used to assess four health agencies’ competence in responding to the needs of high STD-risk communities. Nine dimensions of organizational competence were identified: community participation, assessment of community needs, ensured access to services, community outreach, cultural competence, interagency collaboration, policy development, resource acquisition, and organizational commitment to serve. A competent organization was conceived as one that (a) is committed to serve, (b) works with communities at risk, (c) understands and appropriately responds to their needs, and (d) advocates on their behalf.

Alcohol Policy: Gaps between Legislative Action and Current Research

This paper compares alcohol policies under debate in U.S. state legislatures with policies that have been the focus of research attention. We reviewed the research literature to identify empirical studies of each policy and types of outcome variables analyzed. The two most evaluated alcohol control policies are the minimum legal drinking age and excise tax. Eight other policies had 20 or more studies evaluating them. The remaining alcohol policies received little attention in the research literature. Alcohol consumption and traffic crashes were the most frequent outcomes used in alcohol policy studies. Most studies evaluated policy changes at the state or national level, with few studies of local or institutional policies. During 1997 some 463 alcohol control bills were introduced at state legislatures. Many specific alcohol policies under debate in state legislatures have little research evidence to guide policy decision-making, pointing to areas where future research is needed.

Community Level Correlates of Low Birthweight Among African American, Hispanic and White Women in California

OBJECTIVES

Racial and ethnic groups in the US exhibit major differences in low birthweight (LBW) rates. While previous studies have shown that community level social indicators associated with LBW vary by race and ethnicity, it is not known whether these differences exist among racial or ethnic groups who live in the same neighborhood or community. To address this question, we examined the association of community level features with LBW among African American, White and Hispanic women who live in similar geographic areas.

METHODS

The analysis is based on geocoded birth certificates for all singleton live births in the year 2000 to women residing in 805 California ZIP codes. Community level social and demographic data were obtained from U.S. Census data files for the year 2000 and surrogate indices of population level alcohol and drug abuse and dependence were derived from hospital discharge data (HDD). Tobit and bootstrap analyses were used to test associations with birth outcomes, maternal characteristics, and community level social and demographic features within and across the three groups of women living in similar geographic areas.

RESULTS

The results demonstrate major racial and ethnic differences in community level correlates of LBW. Rates of LBW among African Americans were lower if they lived in areas that were more densely populated, had greater income disparities, were more racially segregated, and had low rates of alcohol abuse or dependence. These associations were different or absent for Hispanic and White women.

CONCLUSIONS FOR PRACTICE

The results suggest that despite living in the same areas, major differences in neighborhood features and social processes are linked to birth outcomes of African American women compared to Hispanic and White women. Further research, especially using multilevel approaches, is needed to precisely identify these differences to help reduce racial and ethnic disparities in LBW.

Risk Environments, Race/Ethnicity, and HIV Status in a Large Sample of People Who Inject Drugs in the United States

INTRODUCTION

We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US.

METHODS

Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated.

RESULTS

Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8-19% of HIV cases among black PWID and 1-15% of cases among Latino PWID to place characteristics.

DISCUSSION

Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection.

Relationship between community-level alcohol outlet accessibility and individual-level herpes simplex virus type 2 infection among young women in South Africa

BACKGROUND

Exposure to alcohol outlets may influence sexual health outcomes at the individual and community levels. Visiting alcohol outlets facilitates alcohol consumption and exposes patrons to a risky environment and network of potential partners, whereas the presence of alcohol outlets in the community may shift social acceptance of riskier behavior. We hypothesize that living in communities with more alcohol outlets is associated with increased sexual risk.

METHODS

We performed a cross-sectional analysis in a sample of 2174 South African schoolgirls (ages 13-21 years) living across 24 villages in the rural Agincourt subdistrict, underpinned by long-term health and sociodemographic surveillance. To examine the association between number of alcohol outlets in village of residence and individual-level prevalent herpes simplex virus type 2 (HSV-2) infection, we used generalized estimating equations with logit links, adjusting for individual- and village-level covariates.

RESULTS

The median number of alcohol outlets per village was 3 (range, 0-7). Herpes simplex virus type 2 prevalence increased from villages with no outlets (1.4% [95% confidence interval, 0.2-12.1]), to villages with 1 to 4 outlets (4.5% [3.7-5.5]), and to villages with more than 4 outlets (6.3% [5.6, 7.1]). An increase of 1 alcohol outlet per village was associated with an 11% increase in the odds of HSV-2 infection (adjusted odds ratio [95% confidence interval], 1.11 [0.98-1.25]).

CONCLUSIONS

Living in villages with more alcohol outlets was associated with increased prevalence of HSV-2 infection in young women. Structural interventions and sexual health screenings targeting villages with extensive alcohol outlet environments could help prevent the spread of sexually transmitted infections.

Bars and nightclubs associated with higher HIV prevalence

BACKGROUND

Alcohol outlet density is positively associated with alcohol consumption and a number of related risk behaviors. However, very little is known about the effects of different types of alcohol outlets on HIV prevalence. The current cross-sectional study examines associations between the number of each type of alcohol outlet and HIV prevalence within 350 cities located in 26 U.S. metropolitan statistical areas.

METHODS

State and local health department and U.S. Census Bureau surveillance data were analyzed from 1056 ZIP codes, where an estimated 39 million people reside. Multilevel negative binomial regression models were used to examine the association between the number of each type of alcohol outlet in ZIP codes and HIV prevalence.

RESULTS

Number of on-premise alcohol outlets within a ZIP code was associated with greater HIV prevalence. In this sample, the presence of one additional on-premise outlet in a ZIP code was associated with a 1.5% increase in the HIV prevalence rate in that location.

CONCLUSION

This study extends previous research by examining the relationship between alcohol outlets and HIV prevalence in a large sample of U.S. ZIP codes. Research is needed to more closely examine the mechanisms by which on-premise alcohol outlets may affect HIV transmission. Effective policies to reduce HIV transmission may include limiting the density of on-premise alcohol establishments.

Using a Health in All Policies approach to address social determinants of sexually transmitted disease inequities in the context of community change and redevelopment

OBJECTIVES

We used a Health in All Policies (HiAP) framework to determine what data, policy, and community efficacy opportunities exist for improving sexual health and reducing sexually transmitted diseases (STDs) in an area surrounding an Army base undergoing redevelopment in Atlanta, Georgia.

METHODS

We conducted a literature review, consulted with experts, mapped social determinants in the community, conducted key informant interviews with community leaders to explore policy solutions, used Photovoice with community members to identify neighborhood assets, and shared data with all stakeholder groups to solicit engagement for next steps.

RESULTS

We identified the following HiAP-relevant determinants of STD inequities in the literature: education, employment, male incarceration, drug and alcohol marketing, and social capital. Quantitative data confirmed challenges in education, employment, and male incarceration in the area. Interviews identified policy opportunities such as educational funding ratios, Community Hire Agreements, code and law enforcement, addiction and mental health resources, lighting for safety, and a nonemergency public safety number. Photovoice participants identified community assets to protect including family-owned businesses, green spaces, gathering places, public transportation resources, historical sites, and architectural elements. Stakeholder feedback provided numerous opportunities for next steps.

CONCLUSIONS

This study contributes to the HiAP literature by providing an innovative mixed-methods design that locates social determinants of STDs within a geographic context, identifies policy solutions from local leaders, highlights community assets through the lens of place attachment, and engages stakeholders in identifying next steps. Findings from this study could inform other redevelopments, community-based studies of STDs, and HiAP efforts.

Alcohol beverage control, privatization and the geographic distribution of alcohol outlets

Background

With Pennsylvania currently considering a move away from an Alcohol Beverage Control state to a privatized alcohol distribution system, this study uses a spatial analytical approach to examine potential impacts of privatization on the number and spatial distribution of alcohol outlets in the city of Philadelphia over a long time horizon.

Methods

A suite of geospatial data were acquired for Philadelphia, including 1,964 alcohol outlet locations, 569,928 land parcels, and school, church, hospital, park and playground locations. These data were used as inputs for exploratory spatial analysis to estimate the expected number of outlets that would eventually operate in Philadelphia. Constraints included proximity restrictions (based on current ordinances regulating outlet distribution) of at least 200 feet between alcohol outlets and at least 300 feet between outlets and schools, churches, hospitals, parks and playgrounds.

Results

Findings suggest that current state policies on alcohol outlet distributions in Philadelphia are loosely enforced, with many areas exhibiting extremely high spatial densities of outlets that violate existing proximity restrictions. The spatial model indicates that an additional 1,115 outlets could open in Philadelphia if privatization was to occur and current proximity ordinances were maintained.

Conclusions

The study reveals that spatial analytical approaches can function as an excellent tool for contingency-based “what-if” analysis, providing an objective snapshot of potential policy outcomes prior to implementation. In this case, the likely outcome is a tremendous increase in alcohol outlets in Philadelphia, with concomitant negative health, crime and quality of life outcomes that accompany such an increase.

Comparing GIS-based measures in access to mammography and their validity in predicting neighborhood risk of late-stage breast cancer

Background

Assessing neighborhood environment in access to mammography remains a challenge when investigating its contextual effect on breast cancer-related outcomes. Studies using different Geographic Information Systems (GIS)-based measures reported inconsistent findings.

Methods

We compared GIS-based measures (travel time, service density, and a two-Step Floating Catchment Area method [2SFCA]) of access to FDA-accredited mammography facilities in terms of their Spearman correlation, agreement (Kappa) and spatial patterns. As an indicator of predictive validity, we examined their association with the odds of late-stage breast cancer using cancer registry data.

Results

The accessibility measures indicated considerable variation in correlation, Kappa and spatial pattern. Measures using shortest travel time (or average) and service density showed low correlations, no agreement, and different spatial patterns. Both types of measures showed low correlations and little agreement with the 2SFCA measures. Of all measures, only the two measures using 6-timezone-weighted 2SFCA method were associated with increased odds of late-stage breast cancer (quick-distance-decay: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.01–1.32; slow-distance-decay: OR = 1.19, 95% CI = 1.03–1.37) after controlling for demographics and neighborhood socioeconomic deprivation.

Conclusions

Various GIS-based measures of access to mammography facilities exist and are not identical in principle and their association with late-stage breast cancer risk. Only the two measures using the 2SFCA method with 6-timezone weighting were associated with increased odds of late-stage breast cancer. These measures incorporate both travel barriers and service competition. Studies may observe different results depending on the measure of accessibility used.

Predictors of high chlamydia and gonorrhea positivity rates among men in the southern United States

BACKGROUND

Routine screening for Chlamydia trachomatis and Neisseria gonorrhoeae in men in the United States is not recommended. However, untreated men remain a potential reservoir for chlamydial and gonococcal infections and reinfection among women. Chlamydia and gonorrhea positivities and associated epidemiology were evaluated among males in the southern United States.

METHODS

Data were analyzed from 603320 males, aged 15 to 60 years, who were undergoing chlamydia and gonorrhea testing in sexually transmitted disease, family planning, correctional, college, and other facilities between 2001 and 2005.

RESULTS

Males screened were primarily non-Hispanic black (63%) or non-Hispanic white (37%). Overall, chlamydia and gonorrhea positivities were both 13%. From 2001 to 2005, the chlamydia positivity increased 32% and the gonorrhea positivity decreased 28%. With increasing age, chlamydia positivity decreased, while gonorrhea positivity remained relatively stable. However, in men aged less than 30 years, both chlamydia and gonorrhea positivities were significantly higher than in men aged 30 years or greater (P < .01). Non-Hispanic blacks had a 5-fold higher risk for gonorrhea and 1.5-fold higher risk for chlamydia than non-Hispanic whites (P < .001). Men living in metropolitan statistical areas had a 1.27-fold higher risk for gonorrhea than men living in non-metropolitan statistical areas (P <.001).

CONCLUSIONS

Chlamydia and gonorrhea positivity rates were high in males in the southern United States relative to the rates among men in the United States and were influenced by demographic and geographic factors.

Sexonomics: a commentary and review of selected sexually transmitted disease studies in the economics literature

BACKGROUND

The purpose of this review is to highlight selected studies in the economics literature that address sexually transmitted disease (STD)-related topics that are typically not examined in the STD literature.

METHODS

Two databases (EconLit and Web of Science) were searched to locate STD-related articles in the economics journals. Relevant articles were also identified in other ways, such as informal discussions with colleagues familiar with the literature. To maintain a focus on unique STD-related topics, studies with topics common in the STD literature (e.g., cost-effectiveness, transmission modeling) were excluded.

RESULTS

Selected STD-related studies in the economics literature were grouped into the following 8 topics: impact of abortion laws and policies on sexual health outcomes; same-sex marriage and syphilis rates; alcohol policy and STD rates; welfare laws and STD rates; discounting the future; HIV disclosure laws; the impact of tolerance for gays on HIV incidence; and economic versus epidemiologic models of HIV dynamics.

CONCLUSIONS

A general theme of STD-related studies in the economics literature is that laws and policies that increased the "cost" of risky sex tended to reduce the demand for risky sex, and therefore reduce the incidence of STDs. Economic research can contribute in novel ways to our understanding of influences on risky sexual behavior at the individual level and STD incidence at the population level. Economists and STD experts could mutually benefit from increased collaboration.

The neighborhood alcohol environment and at-risk drinking among African-Americans

BACKGROUND

Our objective was to examine whether components of the neighborhood alcohol environment-liquor store, on-premise outlet, convenience store, and supermarket densities-are positively associated with at-risk alcohol consumption among African-American drinkers.

METHODS

A multilevel cross-sectional sample of 321 African-American women and men ages 21 to 65 years recruited from April 2002 to May 2003 from three community-based healthcare clinics in New Orleans, Louisiana, was studied.

RESULTS

The alcohol environment had a significant impact on at-risk alcohol consumption among African-American drinkers, specifically liquor store density (adjusted OR = 3.11, 95% CI = 1.87, 11.07). Furthermore, the influence of the alcohol environment was much stronger for African-American female drinkers (adjusted OR = 6.96, 95% CI = 1.38, 35.08).

CONCLUSIONS

Treatment and prevention programs should take into account the physical environment, and the concentration of outlets in minority neighborhoods must be addressed as it poses potential health risks to the residents of these neighborhoods.

Adapting an HIV/STDs Prevention Curriculum to Fit the Needs of Women With Alcohol Problems

Alcohol and drug dependent women are at increased risk for HIV/STDs. This paper discusses how a prevention curriculum, "Safer Sex Skill Building" (SSB), designed to reduce the contraction of HIV/STDs among drug-abusing women, could be modified to fit the needs of alcohol-abusing women in a residential treatment program. Authors modified the SSB by incorporating feedback from expert consultants as well as by engaging study participants in revising the therapy manual in order to create a curriculum that speaks to participants' experiences. Specific steps to assist those who would want to adapt an empirically-based manual-driven treatment intervention are provided.

Racial/Ethnic Composition, Social Disorganization, and Offsite Alcohol Availability in San Diego County, California*

We draw upon social disorganization theory to examine the effects of community characteristics on the distribution of offsite alcohol outlets in San Diego County, California. Of particular interest is whether alcohol availability varies according to neighborhood racial/ethnic composition once measures of social disorganization (socioeconomic disadvantage, residential instability, and racial/ethnic heterogeneity) are controlled. Using data from the 1990 Census and 1993 alcohol license reports, we estimate a series of negative binomial regression models with corrections for spatial autocorrelation. The results show that percent Asian is associated with lower offsite alcohol outlet density. Once socioeconomic disadvantage is controlled, percent Latino is related to lower alcohol availability. Although similar suppressor patterns are observed, percent Black is generally unrelated to outlet density. Consistent with social disorganization theory, socioeconomic disadvantage and residential instability predict increased alcohol availability. Neighborhood racial/ethnic composition is either unrelated or inversely related to outlet density once social disorganization and other neighborhood characteristics are taken into account.

The neighborhood alcohol environment and alcohol-related morbidity

AIMS

The aims of this study were (1) to examine the association between neighborhood alcohol outlet density and individual self-reported alcohol-related health outcomes in the last year-sexually transmitted infections (STI), motor vehicle accidents, injury, liver problems, hypertension and experienced violence; (2) to determine whether the relationship between morbidity and alcohol outlet density is mediated by individual alcohol consumption; and (3) to explore the role of alcohol outlet density in explaining any observed racial and ethnic differences in morbidity.

METHOD

Hierarchical models from a random sample of Los Angeles, CA, and Louisiana residents (N = 2881) from 217 census tracts were utilized. The clustering of health and social outcomes according to neighborhood varied by health problem examined.

RESULTS

There was substantial clustering of STI (intraclass correlation coefficient, ICC = 12.8%) and experienced violence (ICC = 13.0%); moderate clustering of liver problems (ICC = 3.5%) and hypertension (ICC = 3.9%); and low clustering of motor vehicle accident (ICC = 1.2%) and injury (ICC = 1.4%). Alcohol outlet density was significantly and positively associated with STI (crude OR = 1.80, 95% CI = 1.10-3.00), liver problems (crude OR = 1.33, 95% CI = 1.02-1.75) and experienced violence (crude OR = 1.31, 95% CI = 1.13-1.51) although not with other morbidity outcomes. Mediation analyses of morbidity outcomes revealed partial mediation of individual alcohol consumption in the relationship between alcohol density and STI and violence, and full mediation for liver problems.

CONCLUSIONS

Findings support the concept that off-premise alcohol outlets in the neighborhood environment may impact health and social outcomes, either directly or indirectly, through individual alcohol consumption and these associations may be heterogeneous with respect to race and ethnicity.

Changing the density of alcohol outlets to reduce alcohol-related problems

Increasingly, it seems, legal and political debates regarding the granting of new liquor licences are turning to the issue of whether the number and density of alcohol outlets makes a difference in rates of alcohol consumption and alcohol-related harm. But what is the state of the evidence on this question? In this Harm Reduction Digest Livingston, Chikritzhs and Room review the research literature on the effects of density of alcohol sales outlets on alcohol consumption and alcohol-related problems; suggest a new way of conceptualising the relationships; and discuss the implications for reducing alcohol-related harm.

Potential biases due to geocoding error in spatial analyses of official data

Geospatial methods have been used extensively to examine associations between alcohol outlet density and various harms; however, the literature offers too little methodological detail to assess possible geocoding biases in these studies. We used New Zealand liquor licensing and crime data to assess geocoding error. For the year with the best data, 69% of offences could be accurately mapped (91% of those in urban areas, 38% in rural areas). There was considerable urban-rural variation in the accuracy and specificity of location data. If similar error exists in other jurisdictions, previous findings may be biased. Greater consideration should be given to the effects of data quality in geospatial studies, and geocoding methods should be reported explicitly.

Alcohol outlet density and university student drinking: a national study

AIMS

To examine the geographic density of alcohol outlets and associations with drinking levels and related problems among university students.

DESIGN

Cross-sectional survey study using geospatial data, with campus-level and individual-level analyses.

PARTICIPANTS

A total of 2550 students (mean age 20.2, 60% women) at six university campuses in New Zealand (63% response).

MEASUREMENTS

Counts of alcohol outlets within 3 km of each campus were tested for their non-parametric correlation with aggregated campus drinking levels and related problems. Generalized estimating equations were used to model the relation between outlet counts within 1 km and 3 km of student residences and individual drinking levels/problems, with control for gender, age, ethnicity and high school binge drinking frequency, and adjustment for campus-level clustering.

FINDINGS

Correlations for campus-level data were 0.77 (P = 0.07) for drinking and personal problems, and 0.31 (P = 0.54) for second-hand effects. There were consistent significant associations of both on- and off-licence outlet densities with all outcomes in student-level adjusted models. Effects were largest for 1 km densities and off-licence outlets.

CONCLUSIONS

There are positive associations between alcohol outlet density and individual drinking and related problems. Associations remain after controlling for demographic variables and pre-university drinking, i.e. the associations are unlikely to be due to self-selection effects. Increasing alcohol outlet density, and particularly off-licences, may increase alcohol-related harm among university students.

Alcohol availability and neighborhood characteristics in Los Angeles, California and southern Louisiana

The objective of this study was to examine the associations between alcohol availability types and community characteristics in randomly selected census tracts in Southern California and Southeastern Louisiana. Outlet shelf space and price by beverage type was collected from all off-sale alcohol outlets in 189 census tracts by trained research personnel. Three aspects of alcohol availability at the census tract level were considered--outlets per roadway mile, shelf space, and least price by beverage type. Using multivariate analyses, we examined the associations between census tract socioeconomic and demographic characteristics and alcohol availability types. Fifteen measures of alcohol availability were calculated-total shelf space and shelf space by beverage types (beer, malt liquor, and distilled spirits); outlets per roadway mile, per tract, and per capita; and least price by beverage type (including wine). In multivariate analyses controlling for state, male unemployment rate was inversely associated with total shelf space (p = 0.03) and distilled spirit shelf space (p = 0.05). Malt liquor shelf space was inversely associated with percent White (p = 0.02). Outlets per roadway mile was positively associated with household poverty (p < 0.0001), whereas percent African American was inversely associated with outlets per roadway mile (p = 0.03). Beverage-specific least prices were not associated with any socioeconomic or demographic community characteristics. Alcohol availability types, but not least price, were associated with some community characteristics. More research exploring how alcohol availability types vary by community and their relationship to alcohol-related harms should be conducted.

Geospatial methods for identification of core groups for HIV/AIDS

OBJECTIVES

Disease transmission dynamics among members of a sexual network's core group make the group an ideal target for prevention for positives. Identifying the geographic territory of an HIV/AIDS core group is complicated by the numerous factors that may spatially structure cases including alcohol availability. We employ spatial analytic methods in an attempt to identify the geographic distribution of the core HIV/AIDS group.

METHODS

Five year HIV/AIDS detection rates were analyzed for each HIV/AIDS risk category (i.e., MSM, IDU, HRH) at the census tract level (n = 164) in New Orleans using spatial analytic techniques in multivariate models.

RESULTS

MSM was the most common risk category for newly detected HIV cases. Both MSM and IDU cases appeared to decline or enter an endemic phase. Each risk category exhibited unique spatial structure. Among IDUs and HRHs nearly all the spatial structure was explained in terms of the independent variables. However, among MSMs residual spatial structure remained after controlling for independent variables.

CONCLUSIONS

Residual spatial structure in the MSM HIV/AIDS detection rates after controlling for social structure could be explained by the presence of core group members. The study's limitations are noted.

The built environment and alcohol consumption in urban neighborhoods

OBJECTIVES

To examine the relations between characteristics of the neighborhood built environment and recent alcohol use.

METHODS

We recruited participants through a random digit dial telephone survey of New York City (NYC) residents. Alcohol consumption was assessed using a structured interview. All respondents were assigned to neighborhood of residence. Data on the internal and external built environment in 59 NYC neighborhoods were collected from archival sources. Multilevel models were used to assess the adjusted relations between features of the built environment and alcohol use.

RESULTS

Of the 1355 respondents, 40% reported any alcohol consumption in the past 30 days, and 3% reported more than five drinks in one sitting (heavy drinking) in the past 30 days. Few characteristics of the built environment were associated with any alcohol use in the past 30 days. However, several features of the internal and external built environment were associated with recent heavy drinking. After adjustment, persons living in neighborhoods characterized by poorer features of the built environment were up to 150% more likely to report heavy drinking in the last 30 days compared to persons living in neighborhoods characterized by a better built environment.

CONCLUSIONS

Quality of the neighborhood built environment may be associated with heavy alcohol consumption in urban populations, independent of individual characteristics. The role of the residential environment as a determinant of alcohol abuse warrants further examination.

The built environment and collective efficacy

Collective efficacy, i.e., perception of mutual trust and willingness to help each other, is a measure of neighborhood social capital and has been associated with positive health outcomes including lower rates of assaults, homicide, premature mortality, and asthma. Collective efficacy is frequently considered a "cause", but we hypothesized that environmental features might be the foundation for or the etiology of personal reports of neighborhood collective efficacy. We analyzed data from the Los Angeles Family and Neighborhood Study (LAFANS) together with geographical data from Los Angeles County to determine which social and environmental features were associated with personal reports of collective efficacy, including presence of parks, alcohol outlets, elementary schools and fast food outlets. We used multi-level modeling controlling for age, education, annual family income, sex, marital status, employment and race/ethnicity at the individual level. At the tract level, we controlled for tract-level disadvantage, the number of off-sale alcohol outlets per roadway mile, the number of parks and the number of fast food outlets within the tract and within 1/2 mile of the tract's boundaries. We found that parks were independently and positively associated with collective efficacy; alcohol outlets were negatively associated with collective efficacy only when tract-level disadvantage was not included in the model. Fast food outlets and elementary schools were not linearly related to collective efficacy. Certain environmental features may set the stage for neighborhood social interactions, thus serving as a foundation for underlying health and well-being. Altering these environmental features may have greater than expected impact on health.

Reassessing racial and socioeconomic disparities in environmental justice research

The number of studies examining racial and socioeconomic disparities in the geographic distribution of environmental hazards and locally unwanted land uses has grown considerably over the past decade. Most studies have found statistically significant racial and socioeconomic disparities associated with hazardous sites. However there is considerable variation in the magnitude of racial and socioeconomic disparities found; indeed, some studies have found none. Uncertainties also exist about the underlying causes of the disparities. Many of these uncertainties can be attributed to the failure of the most widely used method for assessing environmental disparities to adequately account for proximity between the hazard under investigation and nearby residential populations. In this article, we identify the reasons for and consequences of this failure and demonstrate ways of overcoming these shortcomings by using alternate, distance-based methods. Through the application of such methods, we show how assessments about the magnitude and causes of racial and socioeconomic disparities in the distribution of hazardous sites are changed. In addition to research on environmental inequality, we discuss how distance-based methods can be usefully applied to other areas of demographic research that explore the effects of neighborhood context on a range of social outcomes.

Sexually transmitted diseases in the Southeastern United States: location, race, and social context

Heterosexual transmission of HIV in the United States appears to be following the epidemiologic pattern of bacterial sexually transmitted diseases (STDs) such as syphilis and gonorrhea, disproportionately affecting blacks in the Southeastern region. Nationwide, rates of syphilis and gonorrhea are nearly 30 times higher in blacks than in whites, and this racial disparity underlies most of the regional and county-level differences in rates. The racial disparity cannot be explained by traditional measures of socioeconomic differences, and it cannot be explained by individual-level determinants of sexual behavior, but rather reflects deeper group-level social and environmental factors for which race is a marker. A theoretical model based on previous ecologic studies is proposed to explain the relationship between racial discrimination and elevated rates of STDs in blacks. Key factors in the model include: 1) chronic joblessness, 2) drug and alcohol marketing, 3) social disorganization (or social capital), and 4) male incarceration.

The relationship between the neighbourhood environment and adverse birth outcomes

Intrauterine growth retardation and preterm birth are more frequent in African-American women and women of lower socio-economic status, but the reasons for these disparities are not fully understood. The physical and social environments in which these women live may contribute to these disparities. We conducted a multilevel study to explore whether conditions of mothers' neighbourhood of residence contribute to adverse birth outcomes independent of individual-level determinants. We analysed data from 105 111 births in 1015 census tracts in Louisiana during 1997-98, merging it with data from other existing sources on neighbourhood socio-economic status, neighbourhood physical deterioration, and neighbourhood density of retail outlets selling tobacco, alcohol and foods. After controlling for individual-level sociodemographic factors, tract-level median household income was positively associated with both birthweight-for-gestational-age and gestational age at birth. Neighbourhood physical deterioration was associated with these birth outcomes in ecological analyses but only inconsistently associated with them after controlling for individual-level factors. Neither gestational age nor birthweight-for-gestational-age was associated with the neighbourhood density of alcohol outlets, tobacco outlets, fast-food restaurants or grocery supermarkets. We conclude that measures of neighbourhood economic conditions are associated with both fetal growth and the length of gestation independent of individual-level factors, but that readily available measures of neighbourhood retail outlets are not. Additional studies are needed to better understand the nature of environmental influences on birth outcomes.

Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: a longitudinal analysis

This study tests the effect of neighborhood changes on gonorrhea rates. Prior studies that indicate gonorrhea rates are associated with alcohol outlet density and neighborhood deterioration have been cross-sectional and cannot establish causality. After the 1992 Civil Unrest in Los Angeles, 270 alcohol outlets surrendered their licenses due to arson and vandalism thus providing a natural experiment. We geocoded all reported gonorrhea cases from 1988 to 1996 in LA County, all annually licensed alcohol outlets, and all properties damaged as a result of the civil unrest. We ran individual growth models to examine the independent effects of changes in alcohol outlets and damaged buildings on gonorrhea. The individual growth model explained over 90% of the residual variance in census tract gonorrhea rates. After the civil unrest, a unit decrease in the number of alcohol outlets per mile of roadway was associated with 21 fewer gonorrhea cases per 100,000 (p<.01) in tracts affected by the Unrest compared to those not affected. Neighborhood alcohol outlets appear to be significantly associated with changes in gonorrhea rates. The findings suggest that efforts to control sexually transmitted diseases, including gonorrhea and HIV, should address contextual factors that facilitate high-risk behaviors and disease transmission.

Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV/AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV/AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is "safe" for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.

Structural interventions: concepts, challenges and opportunities for research

Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced. They draw on concepts from multiple disciplines, including public health, psychiatry, and psychology, in which attention to interventions is common, and sociology and political economy, where structure is a familiar, if contested, concept. This has meant that even as discussions of structural interventions bring together researchers from various fields, they can get stalled in debates over definitions. In this paper, we seek to move these discussions forward by highlighting a number of critical issues raised by structural interventions, and the subsequent implications of these for research.

Is There an Association Between Alcohol Consumption and Sexually Transmitted Diseases? A Systematic Review

OBJECTIVE/GOAL

The objective of this study was to conduct a systematic review of published literature on the association between problematic alcohol consumption and sexually transmitted diseases (STDs).

DESIGN

Using a MEDLINE search (1995-2003) and article references, we identified articles that described measures of alcohol consumption and STDs and presented data on their association. For each eligible study, we classified the alcohol consumption measure as specific (problem drinking) or general, and examined study designs, study populations, STD measures, and results.

RESULTS

Of 42 eligible studies, 11 included specific measures of problem drinking, of which 8 found a significant association between alcohol consumption and at least 1 STD. The relationship did not appear to vary according to gender or pattern of alcohol consumption assessed.

CONCLUSIONS

The literature supports an overall association between problematic alcohol consumption and STDs, although their causal relationship cannot be determined with certainty from these observational studies. The findings have implications for prevention planners, clinicians, and individual patients at risk of STDs.

Culture Change and Ethnic-Minority Health Behavior: An Operant Theory of Acculturation

Data on acculturation and ethnic-minority health indicate that acculturation has opposite effects on the same health behavior among different ethnic groups; opposite effects on different health behaviors within an ethnic group; opposite effects on the same health behavior for the women vs. the men of most ethnic groups; and no effect whatsoever on some health behaviors for some ethnic groups. This evidence is so incoherent that it is unintelligible, and hence it continues to be largely useless to health psychology and behavioral medicine. This paper presents a new theory of acculturation that renders these confusing data coherent by predicting such changes in minority health behavior a priori. By so doing, the operant model of acculturation has the potential to improve health promotion and disease prevention and thereby reduce ethnic health disparities.

Stress and physical health: the role of neighborhoods as mediating and moderating mechanisms

Using data from the 1995 Detroit Area Study (N = 1106) in conjunction with tract-level data from the 1990 census, this paper evaluates the relationship between residential stability and physical health among black and white adults. Results suggest that neighborhood-level variation in health is primarily mediated by key sociodemographic characteristics of individuals (e.g., age, race, and socioeconomic status). However, a significant portion of health differentials across neighborhoods is due to disparate stress levels across neighborhoods. Further, high levels of neighborhood stability provide an important buffer to the otherwise deleterious effects of increased stress levels on adults' overall health.

A preliminary investigation of the effects of restrictions on Medicaid funding for abortions on female STD rates

There is evidence in the economics literature that restrictions on Medicaid funding for abortion reduces the demand for abortion. The unresolved question is whether such restrictions also increase safe sex (that is, pregnancy avoidance) behavior among women. This study explores that issue using state-level gonorrhea rates among women for 1975-1995. The rationale is that sexual behavior that leads to greater risk of accidental pregnancies is likely to be highly correlated with sexual behavior leading to greater risk of STD infection. Since gonorrhea has an incubation period of about a week, and is transmitted almost exclusively through sexual intercourse, a change in sexual behavior should soon be followed by a change in gonorrhea rates. The study used a partial adjustment model with lagged-dependent variables estimated using Arellano-Bond's GMM method. Results fail to find any statistically significant evidence that Medicaid funding restrictions are effective in reducing gonorrhea rates. This finding is robust to a variety of alternate specifications and tests. This suggests that restrictions on Medicaid funding for abortion fail to promote safe sex behavior among women.

Secondhand effects of student alcohol use reported by neighbors of colleges: the role of alcohol outlets

This is a study of the secondhand effects of student alcohol use experienced by residents of neighborhoods near college campuses. We examined the relationship of a college's level of binge drinking and the number of alcohol outlets in the immediate area, to lowered quality of neighborhood life through such secondhand effects. Adults from 4661 households in the United States were interviewed through a stratified list-assisted random digit dialing telephone survey. The interview schedule included questions about residents' experiences of secondhand effects of alcohol use such as noise, vandalism or public disturbances. Reports about the quality of neighborhood life provided by respondents residing near colleges were compared with those of respondents who did not live near colleges; and reports of neighbors of colleges with high rates of binge drinking were compared with those of neighbors of colleges with lower rates. The presence of alcohol outlets in these areas was also compared. Residents near colleges and particularly near colleges with heavy episodic drinking reported the presence of more alcohol outlets within a mile. Those neighborhoods were characterized by lower socioeconomic status. Neighbors living near college campuses were more likely to report a lowered quality of neighborhood life through such secondhand effects of heavy alcohol use as noise and disturbances, vandalism, drunkenness, vomiting and urination. A path analysis indicated that the number of nearby alcohol outlets was an important factor mediating the relationship between colleges, especially those with high rates of binge drinking, and such secondhand effects. The results suggest that neighborhood disruptions around colleges due to heavy alcohol use may be reduced by limiting the presence of alcohol outlets in those areas, and the marketing practices that this engenders.

Increased prevalence of herpes simplex virus type 2 among adolescent women with alcohol use disorders

PURPOSE

To determine the relationship between alcohol use disorders (AUDs) and herpes simplex virus type 2 (HSV-2), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections among a sample of sexually active adolescents.

METHODS

Subjects were 240 sexually active male and female adolescents aged 14 to 21 years (mean 17.5 years) recruited from clinical and community settings in western Pennsylvania between 1991 and 1995; 55% had a lifetime history of AUDs (63 females, 69 males) and 45% did not have a lifetime history of AUDs (57 females, 51 males). Participants provided information about demographic factors and sexual behaviors as well as a serum sample that was assayed for antibodies to HSV-2, HBV, and HIV infections. Multivariate logistic regression was used to determine the independent relationship of AUDs to HSV-2 infections among females.

RESULTS

The seroprevalence of HSV-2 infections was 15% among females and 0% among males; the overall prevalence of HBV (1.2%) and HIV (0.4%) infections was very low. Among adolescent females, the seroprevalence of HSV-2 infections was significantly higher among those with an AUD (19%), compared with those without an AUD (10.5%) (adjusted odds ratio 8.1, 95% confidence interval 1.5-44.8, p =.017).

CONCLUSIONS

Adolescent women with an AUD appear to be at substantially increased risk of HSV-2 infection. These results highlight the need to address sexually transmitted diseases among adolescents with alcohol problems.

The population consumption model, alcohol control practices, and alcohol-related traffic fatalities

BACKGROUND

More than 40% of urban traffic fatalities are alcohol related and the rate of such fatalities varies more than 10-fold across U.S. cities. These variations might be explained by differences in local alcohol control policies and practices.

METHODS

We conducted a cross-sectional survey of state Alcohol Beverage Control agencies and local city police departments in 107 cities that participate in the National Highway and Traffic Safety Administration's Fatality Analysis Reporting System. We examined the association of alcohol control practices in 1997 and alcohol-related traffic fatalities per daily vehicle miles traveled, 1995-1997.

RESULTS

Ninety-seven (91%) cities participated. Regulations related to alcohol accessibility, licensure of alcohol outlets, disciplinary procedures of alcohol outlets, and enforcement of blood alcohol concentration laws were associated with lower rates of fatalities. Cities with 9 or fewer of the 20 regulations had 1.46-fold greater alcohol-related traffic fatality rates than cities with 15 or more of these regulations, representing 392 excess deaths annually. Beer consumption was found to be a potential mediator of the effect of regulations on traffic fatalities.

CONCLUSIONS

Alcohol beverage regulations are associated with alcohol-related traffic fatalities. Localities should consider greater restrictions on alcohol accessibility, stricter disciplinary measures for violations, and stricter licensure requirements as a potential means to reduce alcohol-related traffic fatalities.

Socioeconomic status and self-reported gonorrhea among African American female adolescents

BACKGROUND

Socioeconomic status is often used to explain race differences in sexually transmitted diseases (STDs), yet the independent association of socioeconomic status and STDs among adolescents has been understudied.

OBJECTIVE

To examine the associations between socioeconomic status and self-reported gonorrhea among black female adolescents, after controlling for sexual risk behaviors.

METHODS

Interviews and surveys were completed by 522 sexually active black adolescent females residing in low-income urban neighborhoods.

RESULTS

Adolescents whose parents were unemployed were more than twice as likely to report a history of gonorrhea, compared with those with employed parents. Adolescents living with two parents were less likely to report a history of gonorrhea.

CONCLUSIONS

The results of this study indicate that gonorrhea is associated with low socioeconomic status among black adolescent females regardless of the level of sexual risk behaviors. Lower socioeconomic status may be an marker for risky sociosexual environments.

Risk and prevalence of treatable sexually transmitted diseases at a Birmingham substance abuse treatment facility

OBJECTIVES

We evaluated the prevalence of gonorrhea, chlamydia, trichomoniasis, and syphilis in patients entering residential drug treatment.

METHODS

Data on sexual and substance abuse histories were collected. Participants provided specimens for chlamydia and gonorrhea ligase chain reaction testing. Trichomonas vaginalis culture, and syphilis serologic testing.

RESULTS

Of 311 patients, crack cocaine use was reported by 67% and multisubstance use was reported by 71%. Sexually transmitted disease (STD) risk behaviors were common. The prevalence of infection was as follows: Chlamydia trachomatis, 2.3%; Neisseria gonorrhoeae, 1.6%; trichomoniasis, 43%; and syphilis, 6%.

CONCLUSIONS

STD counseling and screening may be a useful adjunct to inpatient drug treatment.

Strategies for syphilis prevention: findings from surveys in a high-incidence area

BACKGROUND

The persistence of syphilis in the United States suggests that a better understanding is needed of the potential for various public health approaches to prevent the spread of the disease.

STUDY DESIGN

The authors conducted surveys of 92 persons with early syphilis, 56 uninfected sexual contacts, and 143 neighborhood controls in the Baton Rouge, Louisiana area. The surveys collected information regarding sexual behavior, access to and use of healthcare services, encounters at sites at which serologic screening for syphilis could be done, and exposure to interventions designed to prevent HIV infection.

RESULTS

All groups reported high-risk sexual behavior. Cases and contacts were more likely than controls to report two or more sex partners in the previous year, but the three groups were similar in the percentage reporting five or more sex partners. Cases had poor access to health care and by some measures this access was less than that of controls. The potential screening site visited most frequently by cases was the public hospital emergency room (40%). Cases were less likely to have been exposed to programs designed to prevent HIV infection than uninfected contacts and controls combined (odds ratios, 0.51-0.66).

CONCLUSIONS

Persons with syphilis were not unlike others in their neighborhoods, suggesting that syphilis is a sentinel event that indicates an entire neighborhood is at risk. Improvements in access to health care for sexually transmitted disease-related symptoms, screening in sites such as public hospital emergency rooms, and emphasizing sexual risk-reduction interventions may limit the spread of syphilis in these neighborhoods. To prevent syphilis in the long term, public health programs should also try to better understand and change other community-level socioeconomic factors that influence sexual behavior.

Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long-haul truckers in Florida

This paper reports the results of ethnographic research to describe risk for human immunodeficiency virus (HIV) infection among long-haul truck drivers and the contexts and factors that influence risk and protective behaviors. Drivers were selected using purposive and snowball sampling at trucking-related businesses along major truck routes in Florida. Interview information was used to categorize truckers' levels of potential risk, describe behavioral characteristics of each group, identify sex partners, and assess perceptions of the risk of HIV infection. One-third of the 71 men interviewed had frequent sexual intercourse on the road with multiple partners, but few ever used condoms. Commercial sex workers were their most frequent partners for on-the-road sex. The risk was compounded by occupational conditions, which motivated truckers to drive long hours, often using drugs to stay alert. Sex, alcohol, and drugs were perceived as quick, effective stress relievers during downtime on long, lonely trips. Despite their high-risk behaviors, truckers tended to consider themselves at low risk for HIV infection and expressed a number of misconceptions regarding HIV transmission. For example, many truckers did not associate HIV risk with heterosexual contact or think that condoms were effective in preventing HIV transmission. In addition, many truckers maintained strong homophobic and anti-government opinions that reinforced their suspicion of safe-sex messages. These findings suggest that high-risk sexual behavior is common among long-haul truckers in the US, who may be at risk for HIV infection primarily because of unprotected sexual intercourse with multiple sex partners. Also, drug use may be associated with HIV risk behavior. The authors recommend establishing prevention programs that are developed by and for truckers, determining HIV seroprevalence rates of truckers, addressing drug and alcohol abuse among truckers, and altering industry policy that keeps truckers on the road too long for their own and others' safety.

"Broken windows" and the risk of gonorrhea

OBJECTIVES

We examined the relationships between neighborhood conditions and gonorrhea.

METHODS

We assessed 55 block groups by rating housing and street conditions. We mapped all cases of gonorrhea between 1994 and 1996 and calculated aggregated case rates by block group. We obtained public school inspection reports and assigned findings to the block groups served by the neighborhood schools. A "broken windows" index measured housing quality, abandoned cars, graffiti, trash, and public school deterioration. Using data from the 1990 census and 1995 updates, we determined the association between "broken windows," demographic characteristics, and gonorrhea rates.

RESULTS

The broken windows index explained more of the variance in gonorrhea rates than did a poverty index measuring income, unemployment, and low education. In high-poverty neighborhoods, block groups with high broken windows scores had significantly higher gonorrhea rates than block groups with low broken windows scores (46.6 per 1000 vs 25.8 per 1000; P < .001).

CONCLUSIONS

The robust association of deteriorated physical conditions of local neighborhoods with gonorrhea rates, independent of poverty, merits an intervention trial to test whether the environment has a causal role in influencing high-risk sexual behaviors.